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M -ST.LUCIE COUNTY'UTILITIES-P.O.BOX 728,FT.PIERCE,FL34982
I NAME
St. Lucie County - PCIS_
10-25-2016 12:05:32 , ACCT.# r
i
16423/3853 ip SERVICE ADDRESS
FERGE, WAYNE
5911 BALSAM DR
FORT PIERCE
E
FL 34962 SUBDIVISION LOT.- BLOCK
E
Amount Tendered:
519.00 !L. BILLINGADDRESS L� -i � '� +'!�/A )1,14 G—� j.
Amount Paid: 519.00 PPI �, r,,
Change Due: 0.00 i PHONE#
Ca MOVE IN/CLOSING.DATE
i
This application hereby request'and authorizes the.Utility to render water and/or sewage disposal
Thank YOU services to the premises,described above in accordance with the Utilities present or future rates,
rales and regulations,which by reference are made apart of this contract.Applicant agrees to pay
i User ID: RODRIGUEZM the Utility promptly for such sery
CUSTices in accordance with the established rules and regulations.
i OMERS DEPOSITS ARE NON NEGOTIABLE OR TRANSFERABLE.
SOCIAL.,SEC/
FED ID C� V# — ,1
SPOUSE SOCIAL SEC. .. I
OFFICE USE ONLY
DATE RECEIVED TJ ,' CASH CHK# ` RECEIVED BY
RECEIV"--D NO 0 3 2016